Most denied claims are not coverage decisions. They are data problems that look like one.
A denial letter reads like a verdict, so most employees either pay the bill or give up. We take the file, find out what actually happened, and pursue the right fix, which is usually a corrected claim or an eligibility update rather than a formal appeal.
Read the reason code before anyone argues medical necessity.
The first job is diagnosis. The explanation of benefits carries a reason code, and that code usually points somewhere other than the plan’s coverage terms. Fixing the wrong problem wastes the appeal.
Coding Errors
A mismatched diagnosis and procedure code, a missing modifier or a wrong place of service will deny a covered service. The fix is a corrected claim from the provider’s billing office, so we call the provider first, not the carrier.
Eligibility Mismatches
A dependent added mid-year, a termination keyed early or a new ID card never loaded all read to the carrier as “not covered on this date.” We check enrollment against the date of service, because an eligibility fix reprocesses the claim without an appeal.
Prior Authorization
When a service needed authorization and did not get it, the question becomes who was responsible for asking. In network, that is often the provider, which is why the member may not owe the bill even when the denial stands.
Genuine Coverage Limits
Some denials are correct under the plan document. We say so early and plainly, so the employee stops waiting for a reversal and starts planning for the bill, a payment arrangement or an exception request.
An appeal wins on the record the plan must hand over, not on how unfair the denial feels.
ERISA’s claims procedure rules give a group health plan participant at least 180 days to appeal a denial, and the right to copies of the documents relevant to the claim, free of charge. Those two rules shape every appeal we help prepare.
Ask for the File First
We request the claim file, the plan provision cited and any clinical criteria used, because an appeal written without them argues against a reason nobody has read yet.
Answer the Stated Reason
The denial notice has to state the specific reason and the plan provision behind it. We build the appeal around that exact reason, with the provider’s records and letter of medical necessity where they matter, so the reviewer has nothing left to deny on.
Watch the Clock
Urgent care claims must be decided within 72 hours; a post-service claim within 30 days of receipt. We track the plan’s deadlines as closely as the employee’s, so a stalled appeal gets escalated, not forgotten.
How a denial is handled depends on who carries the risk.
We keep the employee’s file private and bring HR in only as far as the plan’s structure requires. What changes is who makes the final call.
Fully Insured Plans
The carrier decides the appeal and state insurance rules apply alongside ERISA. The employer is rarely the decision maker, so our leverage is the quality of the file and the escalation path inside the carrier.
Self-Funded Plans
The employer is the plan sponsor and the claims administrator acts under the plan document, so an ambiguous provision is ultimately the sponsor’s question. Where the answer is a legal one, counsel decides, and we bring the facts to them.
Patterns, Not Just Cases
When the same denial repeats across employees, the fix belongs in the plan document, the network or the enrollment feed. We report the pattern so the next claim never denies.
What employees and HR ask when a claim comes back denied.
Should the employee pay the bill while we work on it?
Usually not yet. We ask the provider to hold the account while the claim is reprocessed or appealed, because a paid bill is far harder to recover than an open one.
Does HR see the medical details?
No more than the case requires. We work with the employee directly and keep protected health information out of HR’s inbox, which protects the employee and the employer.
What if the internal appeal fails?
Non-grandfathered plans must offer external review by an independent reviewer. We explain the process from the denial notice and help the employee decide whether the case is strong enough to take there.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
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